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Welcome! Here we publish our views on new research and insights from the field of pulmonary medicine, most often focusing on topics related to exercise, nutrition, and other self-management techniques for those who suffer from chronic shortness of breath.

Whether you have COPD, currently smoke, or are just concerned about persistent shortness of breath and/or cough, read our articles to explore COPD treatment options and self-management techniques that can help you feel better NOW!

Wednesday, May 18, 2011

Every year, over two thirds of U.S. current smokers express a desire to permanently quit. Yet despite this broad desire, only about 40% actually try to quit in any given year and of this 40% who attempt to quit less than 10% are ultimately successful in abstaining from cigarettes for more than six months even with the most effective of treatment options. In fact according to research findings it takes the average smoker up to ten attempts to finally kick the habit permanently.

People who attempt to quit on their own without any medical assistance are the least successful with low single digit success rates. Those who combine long-term counseling with nicotine replacement therapy tend to be the most successful with between 8-17% success rates although some of these reported success rates seem dubious because many rely primarily on self-reported abstinence confirmation versus chemical verification.

Pharmaceutical companies pour many millions of dollars into research each year to find new drugs to boost success rates but so far no major breakthrough. Alarmingly though, a number of the newer pharmaceuticals prescribed by doctors for smoking cessation (anti-depressants) have received Food and Drug Administration warnings for some pretty scary side effects. Meanwhile many other companies tout all manner of other products or services to aid in boosting cessation rates ranging from hypnosis to acupuncture to electronic cigarettes (but with little success in moving the needle).

It is a reminder of how addictive nicotine can be and of how challenging it can be to eliminate a long-term habit.

So what’s a smoker to do?

Well, a simple answer that might just double your odds of success and produce positive side effects versus negative ones is…exercise. Seems hard to believe doesn’t it? Not much research has been done on combining exercise with smoking cessation but the research that has been done has shown some promise. Why is exercise a possible valuable addition to a smoking cessation program? According to the exercise researchers, exercise has been shown in other research to improve mood, assist in weight loss and reduce cravings – all three big-time cigarette smoking withdrawal symptoms.

As a case in point, a new study was published online ahead of print last month in the journal Nicotine & Tobacco Research that demonstrated that study subjects undergoing a 12-week resistance training program (weight lifting) boosted abstinence at 3-month and 6-month follow-up checkpoints by 100% over study subjects who did not exercise during the study. Both the control and resistance training groups received one 15-20 minute smoking cessation counseling session and both groups received nicotine patches during the study period so the only differentiating variable between the two groups was the resistance training program. The absolute abstinence success rate for the resistance training group was 15-16% at both the 3-month and 6-month follow-up checkpoints compared to 8% at both time intervals for the control group. These abstinence results were determined by both self-reported questionnaires and by chemical analysis of each subject’s carbon monoxide levels. [1]

The 12-week resistance training program followed by the exercise group was described the researchers as follows, “Participants engaged in two 60-min RT sessions/week for 12 weeks. The full-body routine (ACSM, 2009b), involved 10 exercises, with set intensity and volume adjusted every 3 weeks. For the first 3 weeks, participants completed one set (10 repetitions) of each exercise at 65%–75% of their estimat¬ed maximal strength. From weeks 4–12, participants complet¬ed two sets per exercise. Weight was systematically increased by a researcher to match gains in strength and maintain inten¬sity at weeks 7–10. Researchers monitored exercise for safety, interactions were minimized, and smoking was not discussed. Participants exercised alone and could attend up to three ses¬sions/week to make up for one missed session in the prior week, with no more than one session/day. All were asked not to engage in RT beyond the supervised sessions or change their other exercise.”

To be fair, the study population was small (25 total subjects) and only 50% of the subjects participated all the way through to the 6-month follow-up checkpoint. So one might argue the success rates of both approaches were actually lower if all subjects were tracked the full way through. That said, those engaged in a resistance training program who did make it all the way through this novel study (novel because it examined resistance training versus aerobic training in conjunction with smoking cessation) did achieve higher abstinence, greater weight loss and lower body fat measurements than the control group.

Other studies probing the addition of an exercise component to a smoking cessation program have also shown promise. In one such 2010 study, researchers found 34% of women participating in the study who participated in a 150 minute per week moderate intensity aerobic exercise program achieved chemically verified abstinence at 6-month follow-up compared to 20% for the control group. In this study, both groups also received one smoking cessation counseling session and nicotine patches for the duration of the study. [2]

In yet another 2010 study examining the effect of either high-intensity (running) or moderate intensity (walking) aerobic exercise on craving to smoke, researchers reported, “Significant group x time interactions were identified, demonstrating significant reductions in craving items after the walking and running conditions compared with the passive control. No significant differences in craving reductions were found between walking and running conditions. Post hoc comparisons found that running condition cravings to smoke scores were reduced for a longer duration post-treatment than post-walking condition scores. The decline in cortisol concentration was attenuated in the running group only. Vigorous exercise has a similar effect to moderate exercise in terms of the magnitude of craving reduction. However, performing bouts of moderate-intensity exercise may be a better recommendation for reducing cravings.” [3]

It therefore seems that adding an exercise program (resistance training and/or aerobic training) to a smoking cessation attempt is worthy of your consideration. Not only might exercise improve your odds of kicking the habit permanently, it has also been shown to notably improve heart rate variability (a risk factor in cardiovascular disease), reduce the risk of lung cancer, and reduce chronic shortness of breath – even among smokers who continue to light up!

For smokers interested in experimenting with an exercise program but who aren’t sure where to start or what specific exercises to do, we have three suggestions for your consideration. First, consider asking your doctor to recommend a specific exercise program. Alternatively, consider visiting a local fitness center and ask to speak to a certified fitness instructor. Associations such as the American College of Sports Medicine create recommended exercise protocols for different health conditions and a fitness instructor should be able to help construct one appropriate for you. They will likely charge for their services but most provide an initial consultation free of charge.

If neither of those options appeals to you, I created the Breathe Better for Life guidebook and companion CD-ROM to assist people with poor respiratory health (smokers and people with lung disease) access the principles and practices of the respiratory medical treatment pulmonary rehabilitation. This treatment option combines aerobic exercise, resistance training, breathing technique training, airway clearing technique training and guidance on other respiratory related topics.

In the Breathe Better for Life guide/CD, I developed an exercise program based on guidelines established by the American Thoracic Society, European Respiratory Society and the American College of Sports Medicine to assist people with poor respiratory health start and maintain an aerobic and resistance training program if they cannot access such a program elsewhere. The CD provides narrated, pictorial step-by-step instructions for the specific resistance training exercises in addition to many other valuable education elements geared to help improve one’s ability to breathe. Click here to learn more about Breathe Better for Life.

Regardless of what exercise program you choose, it is always advisable to review the program prior to starting with your physician to ensure it is appropriate for your particular health status.

Friday, May 6, 2011

Regular readers of our Breathe Better for Life e-letters and Breathe Better Blog are well aware we are strong advocates of antioxidants for people with chronic shortness of breath. Our perspective - we view antioxidants as an excellent addition to a regular exercise program, a Mediterranean-style diet and smoking cessation to reduce inflammation and oxidative stress.

We do not believe that antioxidants will cure, reverse lung disease or improve lung function. However, there is substantial and growing evidence that oxidative stress (an imbalance in damaging pro-oxidant molecules known as free radicals and protective anti-oxidant molecules) is a key contributing factor to the sensation of breathlessness and that most COPD patients are significantly deficient in antioxidants compared to those without persistent shortness of breath.

We are not alone in this belief as a new research paper echoes many of our sentiments. This research review article, published in the journal Current Drug Targets, examines the role of oxidative stress in COPD and the potential of antioxidants as a supportive therapy. In fairness to the review authors, they acknowledge that while antioxidant therapy seems a key area for further exploration there are conflicting study results on the effectiveness of antioxidants for COPD patients. Further, they acknowledge there are few definitive guidelines regarding the optimum human daily dosages for the most promising antioxidants. [1]

Still we’re concerned that it will be decades before enough researchers and practitioners determine these criteria to their own satisfaction. Meanwhile, millions of COPD patients will not learn of the potential benefits that have already been reported in peer reviewed published research for over the past decade.

So, we thought it would be helpful to share some snippets of this research review paper so that readers have access to the emerging potential of antioxidants as a supporting therapy to other traditional COPD treatments.

First, some observations about oxidative stress and COPD offered in the paper’s introduction, “The lung is the organ with the highest exposure to ambient air in the entire human architecture. Due to its large surface area and blood supply, the lung is susceptible to oxidative injury in the form of myriads of reactive oxygen species (ROS) and free radicals. ROS may be produced endogenously by metabolic reactions or have exogenous origins, such as air pollutants or cigarette smoke. Airborne pollutants may result in direct lung damage as well as in activation of inflammatory responses in the lungs. Tobacco smoke is a mixture of over 4700 chemical compounds, including high concentrations of oxidants. Inflammatory cells recruited in airspaces become activated and generate ROS in response to appropriate stimuli.”

“Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease which is characterized by an abnormal inflammatory response of the lungs to external stimuli, the most common being tobacco smoke. This abnormal inflammatory response is attributed to many underlying pathophysiologic mechanisms and one of the most important is the imbalance of oxidative stress and antioxidant defenses.”

Regarding antioxidants, the review authors explain, “In order to provide defense against the oxidative burden, the lungs produce various endogenous agents called antioxidants. The antioxidant species help the lungs ward off the deleterious consequences of a wide variety of oxidants/reactive oxygen species and reactive nitrogen species, either of endogenous or environmental origin. The major nonenzymatic antioxidants of the lungs are glutathione, vitamins C and E, beta-carotene, uric acid, whereas the major enzymatic antioxidants are superoxide dismutases, catalases and peroxidases. These antioxidants are the first lines of defense against oxidants and usually act at a gross level.”

As a side note, the most powerful of these antioxidants is glutathione. That said the human body does not absorb glutathione well when administered directly. Our bodies are much better at producing our own glutathione when we are provided precursors of the antioxidant. The most effective precursor in assisting the body’s production of glutathione is N-Acetyl Cysteine (NAC).

“Oxidative stress is intimately associated with the progression and the development of exacerbations in COPD. A rational approach for the treatment of COPD would therefore be to consider antioxidant intervention not only aiming to neutralize the increased oxidative stress and the subsequent inflammatory response, but also in an attempt to identify the source of oxidants and overwhelm their generation. This can be achieved through two approaches, either by increasing the endogenous antioxidant enzyme defences or by enhancing the non-enzymatic defences through dietary or pharmacological means. To date, however, most clinical trials of antioxidants for COPD have yielded conflicting or disappointing results.”

Despite these conflicting and disappointing results, however, the study authors conclude, “There is now solid evidence for the role of oxidative stress in the development and evolution of COPD. Several biomarkers of oxidative stress have been evaluated by invasive and non-invasive means in patients with COPD. However, further standardization of methods is imperative for the application of such biomarkers in clinical practice. An effective wide-spectrum antioxidant therapy with bioavailability is urgently needed to control the local and systemic oxidative burst in COPD. In that direction, several antioxidant agents have been evaluated as potential candidates for the management of COPD. However, despite some encouraging results, clinical trials so far have failed to elaborately define the type of antioxidant, the regimen and the time period of treatment that may improve clinically meaningful outcomes in patients with COPD. This may be largely due to the incomplete understanding of the pathophysiology of COPD and the differences within COPD phenotypes. Moreover, some of the antioxidants may not reach the correct cellular/tissue compartment where the oxidative damage is taking place. Well-designed clinical trials investigating the potential role of new antioxidants and combinations of antioxidants with existing anti-inflammatory agents may provide new insights in COPD management."

So the takeaway – not enough evidence yet to satisfy researchers and practitioners regarding efficacy and not enough clear guidance on dosages, but clearly an area that will receive great attention in the future due to the unambiguous connection between shortness of breath, inflammation and oxidative stress.

By the way, the antioxidants with most encouraging study results highlighted by the authors:

Whether our Resplenish supplement is of interest to you or not, we recommend you consider bolstering your daily diet with an antioxidant rich dietary supplement and antioxidant rich foods. While it’s true there is no “gold-standard” when it comes to antioxidant dosages for respiratory health it is also true and undeniable that the primary weapons at the disposal of physicians to combat oxidative stress are the natural agents our bodies already use and/or produce – antioxidants.

Tuesday, March 22, 2011

When we think of respiratory health we often concentrate our thoughts on the lungs and the act of breathing. However, respiratory health also encompasses the heart and our circulatory vessels that pump blood carrying oxygen inhaled through the lungs to all parts of our bodies.

Often the impact of chronic shortness of breath therefore is not just seen in lung function tests but in tests to evaluate the efficiency/health of the heart and circulatory system. One such measure is called heart rate variability (HRV). In simple terms, HRV is the amount of time between heartbeats. In general, if there is a large gap in time between heartbeats the HRV is considered to be good. On the flip side, if there is a short gap in time between heartbeats, the HRV is considered bad.

When physicians evaluate HRV, they are most interested to see whether a person’s heartbeats are getting closer together or farther apart. When they are getting closer together, physicians become concerned as this indicates the heart is working harder than it did before. Poor HRV (meaning shorter and shorter gaps of time between heartbeats) is a significant predictor of cardiovascular events such as heart attacks and strokes.

For COPD patients, heart rate variability tends to be poor which makes sense given that the lungs have to work harder to breathe which places greater stress on the heart and therefore the heart has to beat faster/more often in order to help the rest of body perform normal every day functions. As a result, COPD patients experience a greater incidence of cardiovascular events compared to non-COPD populations.

Exercise has been shown in previous studies in non-COPD populations to improve HRV (meaning exercise helps the heart slow down or said another way it helps the heart beat less frequently). Exercise has also been shown in previous studies to reduce COPD patient shortness of breath. So a group of Brazilian researchers recently decided to evaluate whether exercise could also help COPD patients specifically improve heart rate variability. [1]

The study authors described the purpose of their research project as follows,” Nowadays, exercise training is a well-recognized method to treat symptomatic patients with COPD. Its objective is to improve impaired disease outcomes such as exercise capacity, functional status, health-related quality of life and peripheral muscle force, as well as physical activity in daily life. However, little is known about the effects of exercise training programs on HRV changes in patients with COPD.”

In their study, the research team divided 40 COPD patients into two groups. One group of 20 patients participated in a high intensity exercise program patterned on principles and practices of the COPD treatment pulmonary rehabilitation (high intensity group). The other group of 20 patients engaged in a low intensity exercise program that did not push patients as much as a traditional rehab program does (low intensity group). The researchers desired to see whether either program made a notable difference in heart rate variability and whether one level of intensity was more effective in improving HRV than the other.

The study team discovered that the high intensity exercise group experienced a notable mean improvement in heart rate variability (24% on one particular measure known as the SDNN index, and 27% on another measure known as the rMSDD) while the low intensity group saw their HRV worsen between 12-13% on these same two measures. This led the researchers to conclude that high intensity exercise (ala similar to the intensities practiced in pulmonary rehabilitation programs) not only reduce shortness of breath symptoms but also improves heart rate variability. In the researchers own words, “The present study showed that a 12-week high-intensity exercise training program including endurance and strengthening exercises was able to improve HRV outcomes such as the rMSSD and SDNN variables, whereas a low-intensity program of similar duration was not.”

So what did the two different exercise programs entail? According to the study authors, “In the HI group, circuit training including cycling, walking and strength training was performed based on a protocol previously described. For ergometry cycling, the training intensity was set at 60% of the initial maximal work rate; for treadmill walking, at 75% of the average walking speed during the baseline 6-min walking test (6MWT); and for strength training, at 70% of the baseline 1 repetition maximum test (1RM). Increase in work rates and/or duration was assured on a weekly basis, guided by a predetermined schedule and driven by the patients’ perception of their symptoms (Borg-symptom scores). In the LI group, patients progressively performed 5 different sets of exercises including breathing exercises, strengthening of the abdominal muscles (crunches) and calisthenics. Each set consisted of 12 different exercises which were repeated 15 times each. Every 7 sessions, patients began a new set of exercises with an increment on the intensity. Close supervision was provided during both training protocols, which were attended three times per week, for 12 weeks, with 1-h training sessions.”

As we have discussed in many previous articles, exercise is incredibly beneficial to COPD patients and those who otherwise suffer from chronic shortness of breath regardless of disease severity. We have many times recommended COPD patients seek entry to a pulmonary rehabilitation program in their local area if their pulmonologist will provide a referral.

For those people who cannot access a pulmonary rehab program (and unfortunately that’s about 99% of COPD patients and nearly 100% of an expanded audience of people who suffer from chronic shortness of breath but do not carry a COPD diagnosis), we created our Breathe Better for Life guidebook and CD-ROM, www.breathebetterforlife.com, to put the principles and practices of pulmonary rehabilitation directly in your hands. In the guide we created a 12 week exercise program patterned after the guidelines of the American Thoracic Society, the European Respiratory Society and the American College of Sports Medicine for those with poor respiratory health. Our accompanying CD-ROM provides narrated, pictorial step-by-step instructions for the various strength training, stretching and breathing exercises recommended in the guidebook.

Regardless of what exercise program you follow, it is vitally important for COPD patients to start and maintain an exercise program for the long haul. Many research studies have proven the benefits of a regular exercise program for COPD patients (reduced shortness of breath, fewer hospitalizations, improved quality of life, and improved physical strength and stamina to name a few). This study’s results seem to indicate that following a pulmonary rehabilitation style exercise program can also improve heart rate variability and in so doing lessen the potential for a cardiovascular event.

Thursday, March 17, 2011

In January 2011, a group of Iranian researchers reported that COPD patients who engaged in a regimen of three breathing technique exercises four times a day over a ten day period experienced an average 27% reduction in fatigue intensity. By comparison, the control group in the study (COPD patients who received no breathing technique exercises) reported only a 4% improvement in self-perceived fatigue. [1]

In introducing their study findings, the researchers set the stage by noting, “Two significant symptoms of COPD frequently complained by the patients are dyspnea (shortness of breath) and fatigue. Any patient who feels tired for more than 1 month is considered as affected by chronic fatigue. Chronic fatigue is important and common sensation in patients with COPD that interferes with the quality of life but (is) almost neglected. As the disease advances, hard breathing followed by dyspnea and increasing limitation of the patient’s ability to perform daily activities are worsened, and even for doing simple work during the day, the patient gets out of breath and is affected with early fatigue…

Respiratory exercises such as lip-pursing (pursed-lips breathing) or diaphragm respiration (diaphragmatic breathing), are considered as a part of pulmonary rehabilitation programs, which could lead to an improvement in gas exchange, exercise tolerance and quality of life. The goal of respiratory exercises in patients with COPD is for the patients to replace their ineffective respiratory techniques with effective ones and to discharge the lungs from secretions through deep respiratory exercises and effective coughing.”

In other words, the study team speculated that employing breathing techniques that help re-train COPD patients to breathe more deeply and at a slower speed would reduce the sensation of fatigue and enable the patients to participate in more activities and thereby enjoy a higher quality of life.

A total of 60 COPD patients participated in the study (30 in the breathing exercise group and 30 in the control group). Both groups completed a “fatigue severity scale” survey upon enrollment. Then the breathing exercise group received instruction in three respiratory exercise techniques (pursed-lips breathing, diaphragmatic breathing and “effective coughing” – the technique for effective coughing was not identified in the study but was most likely the Huff Cough technique taught in many pulmonary rehab progams).

The COPD patients in the breathing exercise group received instruction and supervision of the proper breathing and coughing techniques and then were asked to practice these techniques 4 times a day for 10 consecutive days. The control group did not receive the breathing/coughing training and were not instructed to utilize such techniques over the same 10 day period. After the 10 day study period, both groups again completed the fatigue survey and the researchers compared the pre- and post- results within and across each group.

For such a short duration of breathing/coughing technique training, the breathing exercise group recorded significant improvements. For example, at the outset of the study 27 of the 30 COPD patients indicated their fatigue was “severe” (the highest level on the survey), while 3 rated their fatigue as “moderate”. At the end of the study, only 16 reported their fatigue as severe (a 41% drop in the number of COPD patients who considered their fatigue severe), 11 indicated their fatigue was moderate, and 3 reported their fatigue as mild. On average, the breathing exercise group demonstrated a 27% improvement in perceived fatigue.

The control group barely moved in their fatigue perceptions. At the outset of the study, 27 of the 30 COPD patients reported their fatigue as severe. At the end of the study, 26 still perceived their fatigue intensity as severe.

These are pretty remarkable findings especially considering the study did NOT involve the core regimen of physical exercise typically offered in a pulmonary rehabilitation program. The only element of pulmonary rehab used in the study was the training and application of breathing and coughing techniques.

The study authors concluded, “Results of the present research showed a reduction in the fatigue intensity among COPD patients under interference as well as a meaningful reverse relationship between the fatigue intensity and the rate of respiratory exercises. In other words, the higher the rate of respiratory exercise applied, the less the fatigue intensity among the samples under interference. The present research also showed that it was the change of respiratory pattern that caused the reduction of fatigue intensity in COPD patients. Patients with COPD have a shallow, fast and insufficient breathing. Through exercises, this type of respiration has improved to diaphragm respiration in which the breathing speed is reduced leading to an increase of alembic aeration. By lip-pursing respiration also, the breathing depth is increased in patients.

Training of respiratory exercises through face to face procedure while implementing treatment procedures may have significant effects on controlling and improving the symptoms, raising the level of awareness and finally, upgrading their quality of life.”

If you are unfamiliar with pursed-lips breathing, diaphragmatic breathing or the huff cough techniques, consider making an appointment with your pulmonologist or respiratory therapist to learn and practice the techniques. For those interested there is a brief overview of these techniques on our Resplenish dietary supplement web site that you can view by clicking here. In addition, our Breathe Better for Life CD-ROM which accompanies our Breathe Better for Life guidebook contains narrated, pictorial, step-by-step instructions of these techniques. To learn more about Breathe Better for Life, visit www.breathebetterforlife.com.

Sunday, February 27, 2011

Breathing difficulties can notably degrade one’s ability to enjoy a good night’s sleep and, according to a new study, poor sleep quality is a significant contributor to COPD patients’ reporting of low quality of life. [1]

As a case in point, the new study found that 74% of the 180 COPD patients enrolled in the research program reported incurring at least one sleep-disturbing respiratory symptom 3 times a week or more. The most common respiratory symptoms cited by study participants included:

These symptoms affected the self-reported average amount of time it took study participants to fall asleep (30 minutes), the amount of time they slept each night (5 hours) and the percentage of patients that awoke during the night (78%) for one reason or another. If the study population is representative of the general COPD population (and there is no reason to think otherwise) then sleep quality is a huge problem for people with respiratory conditions.

To assess whether sleeping difficulties affect COPD patients overall self-reported quality of life, the researchers had the study participants complete three different quality of life surveys (a common respiratory health survey, a sleep specific health survey, and a general health survey) from which the study team conducted a statistical comparison of the correlations.

They discovered a particularly strong correlation between low reported quality of life on the respiratory health survey (St. George’s Respiratory Questionnaire) and poor sleep quality as determined by the sleep specific survey (Pittsburgh Sleep Quality Index).

Ironically, the researchers reported that only about 7% of the enrolled COPD patients indicated they felt excessively sleepy during the day (i.e. difficulty in staying awake) despite the significant percentage of sleep disturbances and quality of life correlation. With that said the researchers concluded, “Patients with COPD have poor HrQOL (self-reported quality of life) and a high prevalence of disturbed sleep. This was correlated with indices of disturbed sleep. Few patients reported daytime sleepiness in spite of severe sleep disturbances. Studies in COPD incorporating HrQOL as an outcome should take sleep quality into account.”

We previously wrote an article for COPD patients and smokers detailing strategies for improving chances for a good night’s sleep. To read that article, click here.

About Me

Mr. Donoghue is the author and publisher of Breathe Better for Life, a self-management guidebook for those who suffer from chronic shortness of breath, www.breathebetterforlife.com.
Mr. Donoghue has devoted the last 15 years of his career to promulgating natural health information and products for those who desire to improve their vitality and longevity.